1. Bringing Sanity to Clinical Work Life Lean in Healthcare Michael Nelson, MD Blue Corn Professional Services, LLC

3. SO How did they do that?

5. Lean • About removing waste for clinical care processes • Importance of tools and culture • 5S, Kanban, Single piece flow, etc. • Transformational change for leads, supervisors, managers and senior leaders (oh and by the way clinicians) • Shingo method • Process • Operators

6. Definitions – Value Added Value Added • Physically or Emotionally Changes the Patient • Patient is Willing to Pay for it • Done right the first time Required Work – Non Value Added • It must be done based on our current regulatory processes TODAY, but does not meet all three (3) criteria above

7. “Leading with Lean”The Possibilities

8. Shingo Lean Implementation –Primary Care Clinic • Eight primary care physicians • 4 internal medicine • 2 family practice • 2 pediatrics • Lean Implementation Jan 08 – April 08

9. Standard Work Area??? • Solution = 5S • Sort (remove infrequently used items) • Set (Everything has a place and everything in its place) • Shine (clean) • Standardize • Sustain

11. Standard Work Area!!!!

12. Creating the Value Stream Map • Direct observation • People flow: patients, providers, staff • Materials flow: medical records, equipment • Information flow: messages, test results • Cycle time measurement • Minutes count but seconds rule • Full work analysis • Videotape providers / staff • Analyze each step of work with the staff person • Determine demand • Determine resources

13. Future State Value Stream Map (where we need to focus improvement efforts to reach desired state) 13

14. Ohno Circle Taiichi Ohno was the Toyota executive largely responsible for structuring and implementing the system known today as the Toyota Production System over four decades after World War II. Ohno was known for drawing a chalk circle around managers and making them stand in the circle until they had seen and documented all of the problems in a particular area.

15. Creating Well Child Check Packets LOCATION:Registration Desk Packets: • Created by Registration Staff • Given to Patients Seen For Well Child Checks • Contains a Variety of Forms & Documents • 47,424 packets created per year

16. Eight Deadly Wastes • Excess Inventory • Excess raw material, WIP, or finished goods. This hides problems such as process imbalances, late deliveries from suppliers, defects, equipment downtime and long setup times. • Motion • Any wasted motion employees make to perform the course of their work. Actions such as looking for, reaching for, stacking, picking up or putting down and walking. • Correction • Producing products that need correction or are defective. Repair, rework, scrap, replacement and inspection are all defect costs. • Employee Participation • Losing time, ideas, skills, improvements and learning opportunities by not engaging or listening to employees.

17. Eight Deadly Wastes • Overproduction • Products being produced in excess of what’s required. Products being made too early. This generates other costs such as overstaffing, storage and transportation. • Waiting (time on hand) • Workers that are standing around waiting on a machine, someone to bring them materials, equipment downtime and no work available. • Transportation • Carrying work in process (WIP) long distances, moving materials more than once, moving parts in and out of storage. • Over processing • Taking unneeded steps to process the work. Inefficient processing due to poor tool or product design and. Producing a higher quality product than necessary.

18. Initial Batch Process CYCLES: 5 TOTAL TIME:3:36 min CYCLE TIME: 0:43 sec OBSERVATIONS?

19. Improved Batch Process CYCLES:5 TOTAL TIME:1:40 min CYCLE TIME:0:20 sec (53% Improvement) IMPROVEMENTS: • Forms Organized by Packet Type • Eliminated Wasted Movement • Error Proofing

20. Single Piece Flow Process IMPROVEMENT: • Build Packets While Waiting For Printer • Eliminated Non-Value Added Time • No Added Time To The Process

21. Primary Care Clinic (FP, IM, Peds)

22. Primary Care Clinic (FP, IM, Peds)

23. Primary Care Clinics (FP, IM, Peds)

24. Lean Culture … “consider culture in a work organization to be the sum of peoples’ habits related to how they get their work done” David Mann Creating a Lean Culture

25. Lean Culture “That is, our idea of culture of a place or organization is a result of what we experience there. In this way a company’s culture is a result of its management system……culture is critical, and to change it, you have to change your management system.” David Mann Creating a Lean Culture

28. Questions